Healthcare Provider Details

I. General information

NPI: 1790845436
Provider Name (Legal Business Name): JOHNSON PEDIATRICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6973 OLIVE BLVD
UNIVERSITY CITY MO
63130-2540
US

IV. Provider business mailing address

6973 OLIVE BLVD.
UNIVERSITY CITY MO
63130
US

V. Phone/Fax

Practice location:
  • Phone: 314-862-7515
  • Fax: 314-862-9214
Mailing address:
  • Phone: 314-862-7515
  • Fax: 314-862-9214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR9G45
License Number StateMO

VIII. Authorized Official

Name: DR. DENISE ROBERTS JOHNSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 314-862-7515